Recently, I received letters from a company representing my new doctor attempting to collect payment on lab work from an annual exam; to my surprise, my insurance claim had been denied. The bill is over $900, but it should be zero. My husband works for the city, so we have great coverage under our HMO, assuming I stay in network, which I made sure to do.
My first reaction was to call the company and make sure they had my BCBS information correct. With my non-hyphenated last name, there seems to be a lot of confusion with doctors’ offices. On the phone the agent told me there was no reason these charges should have been denied. She assured me she would get the matter resolved.
Two weeks later, I received two more collection letters that indicated the charges had been declined by my insurance. I’m not sure how other people would react to this, but if I didn’t know better, I might just scramble to pay the bill, even though my insurance should have covered the costs. Getting repeated threats of going to collections can scare any responsible person concerned with their credit score.
But the reality is that 10% of claims get denied by insurance and less than 1% of those get argued by insurers. Movies like Erin Brockovich make us feel like insurance companies are these omnipotent beings that make decisions against which we have little recourse.
Fortunately, that’s not the case. Here are a few things you can do to argue against an insurance claim denial.
1. Find out why your insurance claim was denied
Sometimes denials come from a doctor entering a code incorrectly or a referral getting lost in an office. Find out the reason first and then reach out to your doctor to try to correct things on their end. They can resubmit the request directly, so you can avoid waiting anxiously on the insurance line.
2. Get your documents together
If the matter cannot be resolved through your doctor, call the insurance company to receive a copy of the denial letter and a copy of your policy. The more information you have the easier it will be for others to help.
3. Seek free help
Many states offer help in understanding coverage and advocating on behalf of patients. For a complete list of state resources, check out Families USA. Additionally, there are many non-profits dedicated to helping families fight unfair insurance claim denials. Here is a list of just a few:
4. Consider legal assistance
If all else fails when an insurance claim is denied, you may need to consider working with a formal arbitrator or suing the insurance company. This can be a very expensive strategy and there is no guarantee it will be successful. The most cost effective way to legally challenge an insurance company’s denial is to go through the state review process. According to a 2010 Georgetown study, this review group favors the patient about 50% of the time. Each state has a different process, so your best bet is to consult with a group like Families USA to determine the best course of action.
Any additional ideas for ways to fight an insurance claim denial?